Objective : Thirty-one colorectal cancers were examined by CT colonography (CTC) before resection.
Methods : The CT attenuation value (the maximum CT density of the whole tumor (Max) and mean CT density within the tumor (Mean)) of each lesion was measured on Multi Planar Reformat (MPR) of enhanced and non-enhanced images. Pathological findings were examined for pathological type, depth, lymphatic invasion and venous invasion. We statistically compared each parameter (Max, Mean and Max-Mean on enhanced and non-enhanced images) with the pathological findings.
Results : Relationships that showed a significant difference (P<0.05) were tumor depth and Max, Max-Mean on non-enhanced images, lymphatic invasion and Max, Max-Mean on enhanced images, Max on non-enhanced images, and venous invasion and Max on enhanced and non-enhanced images. The most sensitive parameter by discriminant function analysis was Max-Mean on non-enhanced images for pathological type (well or not well : average 71% accuracy) and venous invasion (v0, v1 or more than V2: average 77% accuracy); and Max on enhanced images for depth (m, sml or more than sm2 : average 77% accuracy) and lymphatic invasion (ly0, ly1 or more than ly2 : average 74% accuracy).
Conclusions : CT attenuation value on MPR of CTC is related to pathological findings of colorectal cancer.

View full abstract

This case was a 74-year-old female who underwent celiotomy at a local clinic due to enterostasis on December 13, 1976. Subsequently, descending colon cancer was diagnosed, hence a double barreled colostomy and descending colon resection were performed. Since normal activities were unhindered, she went about daily life with the stoma unoccluded. On December 4, 2000, she visited this clinic complaining mainly of lower abdominal pain. Increased dermis temperature near the excluded stoma section was evident. When the inflamed area was drained and x-rays taken, the formation of a fistula with the excluded colon near the stoma was observed. After detailed examination, a diagnosis of excluded colon cancer was made and an operation was performed on February 6, 2001. The tumor was located in the excluded colon region and had involved the jejun and dermis. The cancer and stoma including the fistulated dermis were excised as one unit. The jejun and colon were reconstructed and the stoma occluded. The tumor was a well-differentiated carcinoma, si (jejun, dermis), lyl, vl, n (-), stage IIIa. This excluded colon cancer case is extremely rare in Japan, and so we report this case based on our assessment of its importance.

View full abstract

We report a case of tailgut cyst arising from a presacral lesion. A 52-year-old woman presented at the hospital because of tarry stool. CT scan and magnetic resonance imaging scan showed a cystic mass in the presacral lesion. No tumor marker, such as CEA, CA19-9, or CA125, was elevated. With a pre-operative diagnosis of cystic mass in the presacral space, a complete excision through a trans-sacral approach with coccyx resection was performed. The resected specimen was a smooth-walled, biloculated cyst measuring 13.5×10×6 cm and 3×2×5 cm, respectively. The cyst contained a dark yellowish green fluid. Microscopic exami-nation revealed that the cyst wall consisted of squamous, villous, and columnar epithelia with bundles of smooth muscle conforming to the periphery of the cyst. The mass was diagnosed as tailgut cyst. No evidence of malignancy was found. The addition of coccyx resection to the traps-sacral approach made it easier to keep the surgical site in a good state for completely resecting the tailgut cyst. In Japan, two cases of malignancy have been reported, one of which was a recurrent case arising from remnant cyst after primary surgery for tailgut cyst. Tailgut cysts should be excised completely and need careful follow-up after surgery.

View full abstract

Recto-urethral fistula complicating anal fistula is an extremely rare condition. Recently, we experienced one case whose recto-urethral fistula complicating anal fistula (type IV according to Sumikoshi's classification) could be cured by surgical treatment.
A 70-year-old male had an incision and drainage of a perianal abscess in a clinic, and was referred to our hospital. At admission, he presented with urological symptoms of pneumaturia and nebulous urine. He was diagnosed with a recto-urethral fistula complicating anal fistula from the findings of imaging studies such as cystoscopy, transanal ultrasonography, computerized tomography and magnetic resonance imaging (MRI). In this case, MRI was most useful for the detection of the recto-urethral and anal fistulas, and the fistulas were cured by surgical treatment. Although the management of recto-urethral fistula complicating anal fistula is reported to be difficult, it can be cured by appropriate diagnosis including MRI and surgical procedures.

View full abstract

The effective rates of Imatinib mesylate (IM) therapy against gastrointestinal stromal tumors (GISTs), especially ones located in the stomach, have been reported to be more than 60%. However, it is still unknown how effective IM is against the rare disease of rectal GIST, or how useful it is as a neoadjuvant (NA). We present here a case of rectal GIST, which seemed to be difficult to remove before treatment due to its size and location, but which was resected easily after usage of IM as a neoadjuvant. A 32-year-old man with i difficulty of defecation visited a neighboring hospital. A diagnosis of rectal GIST was made and he was referred to our hospital for treatment. The tumor, located in the lower rectum, was more than 10 cm in diameter. Its diameter was reduced by 23.8% as determined by MRI examination after six months NA of IM. After treatment with IM, an abdominoperineal excision was performed easily because of the tumor size reduction with no injury to the pelvic plexus or hypogastric plexus. The results in this case indicate the usefulness of IM as a neoadjuvant, offering increased resectability of tumors and preservation of sexual and urinary functions.

View full abstract

We encountered an extremely rare case of squamous cell carcinoma of the colon. The patient, a woman aged 72, was examined because of chief complaints of a mass in the upper abdomen and constipation in June 2003. Colonoscopy disclosed a tumor around the hepatic flexure eventuating in marked stricture formation, and a diagnosis of moderately differentiated squamous cell carcinoma was made on biopsy. Although extensive tumor cell dissemination to the peritoneum was noted upon laparotomy, a right hemicolectomy was performed as extensively as possible. Histologically, the tumor was a moderately differentiated squamous cell carcinoma without adenocarcinomatous components, being classified as Type 3, ss, nl (+), P3, H1, M (-), and stage IV. There was no evidence of other primary lesions ; hence the case was diagnosed as primary squamous cell carcinoma of the colon. Despite low-dose FP therapy given to the patient postoperatively, the disseminated tumor continued to grow, and the therapy regimen was switched to CPT-11 plus 5' -DFUR. Serum levels of tumor markers temporarily decreased, but a further increase in the tumor size ensued. The patient died of the malignancy 5 months postoperatively. Squamous cell carcinoma of the colon is an extremely rare malignancy, and a search of the literature has revealed eighteen cases reported in Japan including the present case. In most cases the disease had already advanced at the time of diagnosis and was associated with an unfavorable prognosis. Further accumulation of cases is needed to establish therapeutic approaches in advanced cases and to clarify the underlying pathogenetic mechanism.

View full abstract

A 23-year-old male noted bloody diarrhea on November 2003 and was diagnosed as ulcerative colitis. Because of severe abdominal pain and rebound tenderness, he underwent an emergency colectomy on March, 2004.
At laparotomy, diffuse colitis and ileitis from the Bauhin valve to almost 1 m proximally were recognized. Microscopically, deep ulcers and cellular infiltration were seen similar to colonic inflammation but granuloma and crypt abscess were not found.
After colectomy, ileal inflammation gradually subsided. When he underwent an Real pouch procedure 5 months later, ileitis had completely disappeared both macroscopically and microscopically.

View full abstract

Three cases of gastrointestinal stromal tumor (GIST) originating in the rectum, two of whom developed recurrence, are reported. Case 1 (54-year-old female) underwent surgical removal of leiomyoma in the pelvic region in 1998 and 4 years later local recurrence was found followed by abdominoperineal resection. Histochemically both the primary and recurrent tumors were diagnosed as GIST. Even though case 2 (54-year-old male) underwent abdominoperineal resection against rectal GIST, multiple lung metastases were found 7 months after radical surgery. Exploratory resection of tumor in the right lower lung revealed the metastasis of GIST. Therefore ST1571 was administered orally and remnant tumors disappeared completely after 2.5 years. Case 3 (43-year-old male) had been suffering from either incontinence of feces or narrowing of feces, and had developed anal pain and high fever. While the clinical course suggested periproctal abscess, he was diagnosed as GIST by endoscopic biopsy. Abdominoperineal resection was performed against the rectal tumor. We summarize the reported cases of rectal GIST in Japan and discuss features of recurrence of GIST within the context.

View full abstract

We investigated the utility and complications of self-expandable metallic stents for patients with inoperative malignant colorectal stricture. Primary colorectal cancer comprised approximately half of 77 case reports from Japan ; among the 17 patients treated at our hospital, rectal cancer comprised half of the cases. For the 94 cases in total, the insertion success rate was 100% and the rate of clinical effectiveness was 93%. Re-stricture occurred in 12 cases (13 %) and half of these cases were successfully treated by stent-in-stent. Migration occurred in 7 cases (7%) and perforation occurred in 3 cases (3%). Duration of EMS insertion was 1 to 576 days (average, 145 days). There were no deaths related to the procedure. This procedure makes colostomy unnecessary ; moreover, it is cheaper, safer, highly effective and requires shorter treatment time. EMS insertion is a palliative alternative to colostomy for patients with inoperative malignant colorectal stricture. However, in Japan the widespread application of EMS insertion has been slowed by the lack of national health insurance coverage for the procedure. We eagerly await a swift reversal of this policy.

View full abstract

Patients who had undergone surgery for colorectal perforation were reviewed to evaluate the factors that affect prognosis. There were 24 patients (14 men, 10 women ; mean age 65.2 years, range 26-85 years) treated between January 1991 and December 2003. The causes of colorectal perforation were diverticulitis (n=7), malignancy (n=6), iatrogenic damage (n=5), idiopathic condition (n=3), inflammation (n=2) and injury (n=1). The sigmoid colon and rectum were the most common site of perforation. Five patients who died after surgery were compared with 19 patients who were discharged from the hospital. Significantly different factors were the longer duration from the onset of perforation to surgery, the presence of preoperative shock and other associated diseases. There were five patients with perforated colorectal cancer. Curative resection was the primary treatment in four and all remain alive without recurrence. The other one with metastatic liver tumor underwent sigmoidectomy 18 days after colostomy and remains alive under chemotherapy. In conclusion, the earlier treatment and management of associated diseases are mandatory in patients with colorectal perforation. Primary curative resection for perforated colorectal cancer is the treatment of choice in the absence of the above risk factors.

View full abstract